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Proximal tibial fracture
The document discusses the management of proximal tibial fractures in elderly patients, emphasizing the importance of classifying fractures and planning treatment based on their complexity. It outlines various fracture mechanisms, classifications (including Schatzker), and the necessary investigations for accurate diagnosis. The document also details surgical and non-surgical treatment options, highlighting the significance of anatomical reduction, soft tissue preservation, and early mobilization for optimal recovery outcomes.
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Proximal tibial fracture
- 1. Dr Smarajit PatnaikDNB Senior Consultant Orthopaedic Surgeon Apollo Hospitals Bhubaneswar Proximal Tibial Fractures in the elderly: Surgical considerations
- 2. Objectives • Understand complexity •Appreciate mechanics • Classify • Achieve a rational treatment plan –Articular –Metaphyseal –Soft tissues
- 3. Tibial plateau • Articularfracture by definition • Aim for: –Perfect reduction of articular surface –Absolute stability (compression)
- 4. Caused by avariety of forces: •Valgus/varus deformation •Torsional forces due to slip and fall •Axial compression •Flexion/extension •Direct trauma Fracture mechanisms
- 5. Fracture mechanisms • 1%of all fractures: – Lateral plateau: 60% – Medial plateau: 25% – Bi-condylar: 15% • Two subgroups exist • Young patients with good bone stock—high- energy • Elderly patients with osteoporosis—low- energy
- 6. Classification of proximal tibialfractures (41-A)• A: extraarticular – A1: avulsion – A2: metaphyseal simple – A3: metaphyseal multifragmentary •
- 7. Classification of proximal tibialfractures (41-B) • B: partial articular – B1: pure split – B2: pure depression – B3: split-depression
- 8. Classification of proximal tibialfractures (41-C)• C: complete articular – C1: articular simple, metaphyseal simple – C2: articular simple, metaphyseal multifragmentary – C3: articular multifragmentary
- 9. Schatzker Classification • SchatzkerI – Split of the lateral tibial plateau without depression
- 10. Schatzker Classification • SchatzkerII – Split and depressed fracture of the lateral tibial condyle
- 11. Schatzker Classification • SchatzkerIII – Isolated depression of the lateral tibial plateau
- 12. Schatzker Classification • SchatzkerIV – Fractured medial plateau
- 13. Schatzker Classification • SchatzkerV – Bicondylar fracture
- 14. Schatzker Classification • SchatzkerVI – Bicondylar fracture and diaphyseal/metaphyseal dissociation
- 15. Posterior shear fracture •Pure posterior fracture fragments • Does not fit into Schatzker’s classification, may be bicondylar, or a knee dislocation variant. • Needs posterior approach
- 16. • Usually cruciate ligamentavulsions. Intercondylar eminence fracture
- 17. Etiology: high-energy trauma Extensivedamage to the soft tissues: • Contusions • Open injuries • Compartment syndrome • Peroneal and tibial nerve injury • Popliteal artery injury
- 18. Etiology: low-energy trauma •Axial trauma • No contusions • Closed injuries • Less soft-tissue problems • Axis deviation • Fixation problem (osteoporosis)
- 19. Etiology • In low-energytrauma the problem is: – Mechanical—fixation in osteoporotic bone • In high-energy trauma the problem is: – Biological and associated with damage to the soft tissues
- 20. Investigations • X-ray – APand lateral views – 45°oblique views • Computed tomography (CT) • Magnetic resonance imaging (MRI) • Angiography
- 21. • Plain X-Ray: •Supine AP and lateral view for all patients • Internal and external oblique view • Obtain contralateral AP and Lateral (compare) • Tibial plateau view: AP with knee extended and beam directed 15 degrees caudally • CT scan: • increases the diagnostic accuracy • indicated in cases of articular depression • shown to increase the interobserver and intraobserver agreement on classification in tibial plateau fractures • excellent adjuncts in the preoperative planning Radiology
- 22. • MRI: • alternativeto CT scan or arthroscopy • osseous as well as the soft tissue components of the injury • cost prohibitive for use in standard situations • Duplex US and Arteriography: – To evaluate associated arterial injury. Radiology
- 23.
- 25. Personality of thefracture • Soft-tissue damage • Degree of fracture displacement • Degree of comminution • Degree of joint involvement • Osteoporosis • Neurovascular injury • Complex ipsilateral injuries and polytrauma
- 26. Goals of treatment •Decompression and preservation of soft-tissues • Reconstruction of joint surfaces • Reconstruction of normal mechanical axis • Early motion
- 27. Nonoperative treatment • Nojoint step > 2 mm • No axial instability • Severe osteoporosis • General and local contraindications (eg, medical illness)
- 28. • Non-operative management: –Indicated for non-displaced or minimally displaced fractures • Method: – Protected weight bearing and early range-of-knee motion in a hinged fracture brace. – Isometric quadriceps exercises and progressive passive, active-assisted, and active range-of- knee motion exercises. – Partial-weight bearing (30-40 Ib) for 8 to 12 weeks with progression to full weight bearing. Management
- 29. Schatzker’s principles oftreatment • Immobilization > 4 weeks: residual stiffness • ORIF and immobilization: even more residual stiffness • Regardless of treatment: mobilize early • As long as mobility is preserved a secondary reconstructive procedure is possible
- 30. • Impacted fracturescannot be dislodged by traction or manipulation • Depressed articular surfaces remain permanent defects Schatzker’s principles of treatment
- 31.
- 32. Emergency operative treatment • Vascularinjury • Compartment syndrome • Open fractures • Gross dislocation • Floating knee • Polytrauma
- 33. What if aproximal tibia comes on day 2 of injury ? • 1) Take up immediately for surgery • 2) Wait for investigations and operate on second • 3) Wait for 8-10 days and operate later • 4) Would operate after 1 month
- 34. Delayed surgery (damagecontrol surgery) • Use of a temporary spanning external fixator will allow: – Optimal recovery of soft tissues, appearance of wrinkle sign. – Preserve length and axis • Further imaging and preoperative planning • SCAN,SPAN,PLAN
- 36. Surgical approach • Minimallyinvasive versus ORIF – ORIF: anterior, antero lateral, (postero)medial, (postero)lateral • Prepare for bone grafting • Knee flexed position, floating position and combined approach • Tourniquet • Fluoroscopy
- 37.
- 38. Intraoperative procedure • Exposeligamentous and meniscal structures • Reconstruct the joint surface! • Support the joint surface with bone or substitute • Buttress with a plate (conventional) • Repair the ligaments and menisci to achieve joint stability
- 39. • Type I: –Closed reduction then stabilized cancellous lag screws with washers to gain compression. • Type II: – OR and elevation of depressed fragment – Bone graft is placed to support the elevated fragments – Screws are placed across the reduced split fracture fragments in lag mode Operative treatment
- 40. • Type III: –elevation through cortical fenestrations – supported with subchondral screws and bone graft • Type IV: – requires a medial buttress plate to counteract the shear forces acting on the medial plateau – lag screws alone are not sufficient to stabilize these fractures Operative treatment
- 41. Percutaneous screw andwasher fixation its importance 42
- 43.
- 45. Locked internal fixators •Tibial locked internal fixators are available • Locking head screws provide better support than conventional screws in a short metaphyseal fragment • Percutaneous insertion preserves soft tissues
- 48. • Anatomical reduction • Lagscrew fixation • Locking head screws for angular stability • Improved pull-out resistance
- 56. Fine wire fixatorfor severe soft-tissue injuries • Reconstruction of the joint surface • Reconstruction of stable axes • Early motion • Excellent results - (Schatzker IV, V, and VI)
- 58. Fine wire/Hybrid • Exoskeletonallows: – Attention to soft tissues – Application of relative stability to the metaphyseal/diaphyseal component • Problems: – Fine wire irritation – Intracapsular portals – Must get articular reduction first! – Patients unhappy!
- 59. Results of ORIFon tibial plateau in general • Depends on the fracture type • Depends on soft-tissue management • Depends on realization of goals • Can be excellent even in high-energy trauma: – Average range of motion 0–120°(87%) – No deterioration in the 2nd 5 years – Good prognosis
- 61. Take-home messages • Anatomicalreduction and rigid fixation of joint surface—absolute stability • Functional reduction and stable fixation of metaphysis—relative stability • Restoration of joint stability by appropriate soft-tissue reconstruction • Early active movement • Non operative treatment has a role in severe osteoporosis in elderly • Respect the soft tissues!!!
Editor's Notes
- #2 Published: August 2013
- #5 References: Kennedy JC, Bailey WH. Experimental tibial-plateau fractures. Studies of the mechanism and a classification. J Bone Joint Surg Am. 1968 Dec;50(8):1522-34.
- #39 Images courtesy of AO Surgery Reference.
- #53 The screws indicated should probably be omitted in line with current bridging osteosynthesis practice. Lecturer can choose to challange participants on this point prior to showing this slide.